What happens to plastic surgery leftovers?

Sally Williams -Apr 9, 2012

Recycled body bits ... there are many uses for our excess baggage.

Last October, Rebecca Travers, a PhD student, got in her Renault and drove to a private hospital in Bath, England, known for its cosmetic surgery. Travers wasn't interested in having a tummy tuck. She wanted the fat that was left after the tuck was done. At the appointed time, and with the patient still sedated, the theatre staff produced the sample - abdominoplasty can result in quite large pieces of intact flesh and this weighed around 1kg. Travers placed it into her container - a metal tray in a plastic box - and then she drove back to Bath University to begin her analysis.

She was investigating adipose tissue - fat - and is part of a growing number of medical researchers and specialists who see in cosmetic surgery what many miss: the waste. Cosmetic surgery, after all, is all about removing excess fat and tissue. The mission of these experts is to rescue it from the incinerator.

"We don't have any figures," says Sian Harding, professor of cardiac pharmacology, Imperial College London, and one of the authors of the report Human Bodies: donation for medicine and research by the Nuffield Council on Bioethics, "but it's a growth area and is driven by some very interesting developments."

For years, people thought fat was something to hide or apologise for. "It was just the soft squidgy bits no one really wanted," says Dr Dylan Thompson, senior lecturer in human and exercise psychology at Bath University. But recently, scientists have discovered that it's much more than "just" fat. It releases hormones and proteins and offers all sorts of insights into the human body.

And now it's being mined for a multitude of uses. Dr Thompson and his team are studying fat to investigate the impact of exercise. Other scientists are working on everything from turning fat into stem cells (far less controversial than using human embryos); recycling it for breast reconstruction (thus doing away with toxic implants); and investigating obesity. In short, fat has became an enormously significant material. The challenge is how to get hold of it.

In 2000, Dr Thompson started recruiting volunteers. "We put advertisements in newspapers, local GP practices and emailed big companies, asking people to come to the university and take part in experiments," he explains. Once in the lab, he would remove a sample of fat from their stomachs with a needle. "Typically we would get anything from between half a gram and a gram of tissue." Tiny amounts, in other words. Which meant they were very limited in the type of observations and experiments they could do. Harvesting fat from animals wasn't an option, because besides from ethical concerns, "you get such tiny amounts [of fat] from a mouse or a rat", he says.

In 2008, Dr Thompson took a six-month sabbatical at Toulouse University, and he was stunned by what he discovered. "Researchers had been using surplus tissue from cosmetic surgery for years. They didn't do anything like we did; they never recruited volunteers, they simply capitalised on this spin-off from local clinics." Dr Thompson thought of the challenges back home. He'd recruited some 500 donors over 10 years, but could never quite get enough adipose tissue. And although the fat extraction technique wasn't painful exactly, it did leave the volunteer with a nasty bruise. "It really was a no-brainer to try and do the same thing here in the UK as well."

Since last autumn, his team have collected around six kilograms of human fat from the Bath clinic. This is nothing compared to Cytori, a "cell therapy clinic", in San Diego, working on recycling fat for breast reconstruction. "We've recently processed our 3000th sample of fat - a grand total of more than 5000lbs [2268kg] over nine years," says a spokesperson. San Diego, it transpires, has an abundance of fat.

Recycling intimate body parts is not new, and in most people's minds is tied up with organ donation for heart or liver transplants. "Tissue donation", on the other hand, covers anything that isn't a vital organ: blood vessels, bone marrow, corneas, heart valves, skin, even bones (which can be pulped down and used for hip implants). The source of such material tends to be families donating the bodies of deceased loved ones to research; and surgical operations - for example, a diseased heart can be harvested for valves (for patients) and tissue (for pathologists). Cancer growths can also be a rich supply of material. "People who've had tumours removed are usually very happy to have cells grown out of those tumours that can then be tested for new drugs for cancer," says Professor Harding.

A whole industry has grown up around tissue collection. Firms have stepped in to open "bio banks" where human material is collected, stored in well-regulated freezers and sold. (PromoCell, the German-based company, for instance, charges around £300-£600 for a batch of adipose cells - not tissue - enough for several experiments.)

And ever since the Alder Hey Children's Hospital scandal in Britain in 1998, when organs were stripped, without parents' permission, from babies who'd died at the hospital, guidelines have been set to regulate the business more carefully. The Human Tissues Act, which came into effect in 2004, aims to "ensure that human tissue is used safely and ethically, and with proper consent".

From the outside, L'Oreal Predictive Evaluation Center looks like the other featureless research laboratories in the Gerland Technopole, a bioscience park in a suburb of Lyon. But inside is a calm concoction of glass, potted plants and bleached-wooden floors. It could be an architect's office, or a health spa, were it not for the disconcerting sight of staff in full-body suits and masks, hunched over Petri dishes in sealed-off sterile rooms. The business of the centre is tissue engineering. In short, it's a skin factory.

Artificial human skin - or rather the top layer, a living epidermis - was first invented under the name of Episkin, in the early Nineties, by Dr Estelle Tinois-Tessonneaud, a PhD student from Lyon University.

L'Oreal bought Imedex, the company which manufactured Episkin in 1997, and went on to invest over £500 million in development because, with the proposed changes in testing laws, the industry knew it had to make a change. (Since 2009, animal testing of cosmetic products or ingredients has been banned in the EU; an outright ban will take effect next year.)

In 2007, Episkin was authorised by the European Centre for the Validation of Alternative Methods (ECVAM), as a means of testing for skin irritancy. This was a green light for growth. Last year, L'Oreal doubled the area of its centre in Lyon, quadrupled the staff and expanded the focus to include not just Episkin but RealSkin (full-thickness skin, with a living dermis as well as epidermis) and an artificial human cornea - the outer layer of an eyeball.

On the day I visited, laboratory assistants were soberly applying pink hair conditioner on to trays of skin the size of a Polo mint, and as thin as a cigarette paper. In another lab it was being blasted with UV light to assess the protective power of sun cream. Fake skin hasn't entirely replaced animal testing. There are still 100 or so studies that have to be done on animals because alternative methods to test some effects haven't been perfected. But so far about 3000 raw materials and finished products have been tested here. It even looks like skin - if you saw skin deprived of a blood supply, which not many of us do. In 2010, it "grew" 135,000 units of tissue; last year, 150,000.

And how do you make skin? First, you need real skin, specifically that removed from women's breasts during cosmetic surgery. "I used to work with samples from breast reduction and tummy reduction," says Dr Tinois-Tessonneaud, now Episkin site manager, and a slender, poised woman in her late forties. "But I must admit I prefer to work with breast reduction skin because the skin is nicer. For the tummy, the skin has been extended."

Not much is needed to kick-start the process where keratinocytes (the main type of cell in the top layer of skin) are grown on a collagen matrix and become the five layers of the epidermis. The ratio is 1:3; for every donated skin cell, the clinic engineers three more.

The source is local - two cosmetic surgery clinics in Lyon. "We maybe use five samples a year or one a month, it depends," says the centre's director Francois Soler. Each sample is around five inches square.

And because Episkin has a double benefit - it appeals to consumers because it protects animals; it appeals to the industry because it's "human" and so offers a more accurate reading than testing cosmetics on rabbits, say - it is much in demand. Episkin doesn't stay in the lab in Lyon; it's sold to 150 companies around the world in such countries as Japan, the United States, Korea, India, Brazil (for them to test their products or do research). There are now five or six other companies reconstructing skin on an industrial level, and the centre has a sister company in China.

So, what of the donors? Skin, obviously, belongs to the person who donates it.

There are few simpler ethical notions than this one. Which is why in the past few years, guidelines have been strengthened. The Nuffield Council on Bioethics stresses that "The person's own willingness to be a donor is central, ensuring the material is 'properly given' rather than 'improperly taken."'

"There has to be a protocol and a properly worded consent form for the patients to sign and agree and then the tissue has to be collected in an appropriate way," explains Fazel Fatah, president of the British Association of Aesthetic Plastic Surgeons (BAAPS). And the centre follows this to the letter: "Before the plastic surgery operation we give the surgeon papers for the patient to sign," says Dr Tinois-Tessonneaud. "This is to say that she is consenting, that she will be anonymous, that we can't pay her - it's a free donation from clinics."

And most patients are happy to donate. "I wouldn't really care what happened to it," says Charlotte Hanbury, cosmetically enhanced after a breast reduction and a tummy tuck three years ago. "I certainly didn't feel attached to it. I was glad it was gone, and I'd rather that - a cosmetic surgery procedure which is something you choose - than blind beagles." It appealed to her sense of thrift - her swags of unwanted flesh being put to good use. Nor did she mind a part of herself travelling to research labs around the world. But as soon as money entered the equation with the realisation that her cells could become a commodity, she became less clear. "That's kind of strange," she says.

"There is an intrinsic unfairness about companies making money out of people's tissue," acknowledges Professor Harding, "but to say you have to pay a specific amount of money to the donor would strangle very good research." Moreover, Soler is not convinced the commercial aspect is a stumbling block. "Donors are informed of what we're going to do," she explains. "We say we're going to do research, as well as produce reconstructed skins, and they freely give their skin. They know."

Back in Bath, Dr Thompson is digging a little deeper in his search for fat. He has ethical approval to recruit 60 patients over two years, and so far he's still in single figures. This doesn't illustrate a lack of will on behalf of the donors; rather logistical complications.

"Often the procedure is very late at night and so by the time we get the sample back to the lab, it's too late. Fat doesn't last very long," he says. Moreover, it has to be fat from tummy tucks, because that produced from liposuctions is too degraded. "The enzyme they use which helps to break the tissue down so they can suck it out is very aggressive," he says.

So, he hopes to start working with a second clinic. "It's such an opportunity," he says, "it means we can answer questions we could never have answered using our more conventional approach. And if this tissue wasn't in our lab, it would be sitting in a bin somewhere slowly breaking down."